|
||||||
|
|
|
|
|||||||||||
|
|||||||||||||
| ||||||||||||||||||||||||||||||||||||
The well-documented increase in obesity in the U.S poses new challenges forpre- and post-surgical management to the primary care provider.
"I would be very surprised if there is a primary care practice in theUnited States that doesn't have at least one patient who has had some form ofbariatric surgery," says Christopher Still, DO, medical director of theCenter for Nutrition and Weight Management at the Geisinger Health Care Systemin Danville, Pa.
PRE-OP
The role of the primary care provider preoperatively largely depends onlocal resources. If a comprehensive program at a specialized bariatric surgerycenter is nearby, the patient may only need a referral. In other areas, theprimary care provider may be responsible for ordering various preoperativetests, including standard blood tests, echocardiograms, or stress testing, aswell as liver and gallbladder ultrasounds. Often, the primary care providerwill coordinate management of comorbid conditions, such as hypertension,diabetes, and sleep apnea, to help "tune up" the patient prior tosurgery.
Another role for the primary care provider is to work with the patient tolose weight. "Recent data suggest that there is a much lower risk forcomplications in patients who lose 5–10% of their weightpreoperatively," says Harvey Sugerman, MD, emeritus professor of surgeryat Virginia Commonwealth University in Richmond. "This helps shrink theliver, makes surgery less difficult, and lessens the cardiovascularrisks."
Primary care providers should thoroughly understand the exact proceduretheir patients will undergo (see sidebar, "Bariatric Surgery at aGlance"). Different surgeries carry different risk patterns bothimmediately and over the long term (see chart, "Potential ComplicationsAfter Bariatric Surgery"). Communication between doctors and other careproviders is imperative as care for the patient will require coordinatedmanagement for the rest of his or herlife.
POST-OP
Serious complications from bariatric surgery usually are seen within thefirst 4 weeks. The most common serious near-term complications are anastomoticleakage and pulmonary embolism, which according to one recent study accountfor almost all postoperativemortality.1
Anastomotic leakage may develop within the first month. Although it usuallymanifests during hospitalization, any patient presenting with sustainedtachycardia >120 beats per minute, fever, shoulder pain, abdominal pain,shortness of breath, increased respirations, and/or hypotension should bereferred immediately to the surgeon.
Nausea and vomiting are other relatively common complications. Oftenrelated to the size of the gastric pouch, this condition also may be seen inpatients who eat too many carbohydrates following surgery. It usually istreated with rehydration using intravenous fluids and antiemetic medications.Supplementation with folate/thiamine and a multivitamin is recommended forpatients with persistent vomiting.
"I generally prefer that the patient call the surgeon for anyconcerns during the first week or so," says Alan Wittgrove, MD, medicaldirector for Wittgrove Bariatric Center in La Jolla, Calif. "After thattime `joint custody'starts."
MANAGING CHANGES IN COMORBID CONDITIONS
The primary care provider may manage major changes in comorbid conditionsimmediately following surgery. About 90% of diabetic patients will becomenormoglycemic within 2 or 3 days, well ahead of major weight loss, accordingto Wittgrove. Close glucose monitoring to appropriately adjust insulin dosesis important. Oral antidiabetic agents usually can be stopped entirely.
It is often possible to wean patients with high blood pressure fromhypertensive medications. Similarly, sleep apnea and other breathing problemsprogressively improve.
|
Some women may become more fertile following bariatric surgery; however,many experts suggest patients wait 12–18 months before becoming pregnantbecause the rapid weight loss and altered absorption of nutrients have beenlinked to neural tube defects and other pregnancycomplications.2 Inaddition, since adequate absorption of oral contraceptives cannot be assumed,additional birth control methods should be discussed.
LIFELONG ADHERENCE
The personal physician should continue to monitor certain conditions thatmay affect the patient for life. For example, if the patient had malabsorptivesurgery, his or her response to some medications may change.
Clinicians should not prescribe extended-release drugs because reducedtransit times and changed intestinal anatomy influence the amount ofmedication that reaches the bloodstream. In the immediate postoperativeperiod, medications with small therapeutic windows, such as lithium oranticoagulants, should be monitored closely, and dosing changed as indicated.Clinicians should not prescribe nonsteroidal anti-inflammatory agents, whichincrease irritation and bleeding.
At every visit the primary care provider should assess the patient'snutritional and supplementation adherence while reinforcing the importance ofproper nutrition. Iron, vitamin B12, folate, and calcium/vitamin D are thedeficiencies most often seen in this population (see sidebar,"Postoperative NutritionalSupport,").3
It is not unusual for patients to start feeling better and decide they needno longer follow the prescribed regimen. Personal physicians can remind thesepatients that they are feeling better because of the treatment and that theymust remain on it throughout their lives.
The emotional outcome of surgery is another area where the primary careprovider may have an advantage over the surgeon because the primary careprovider usually sees the patient more often. Although most patients findtheir quality of life and pre-existing depression dramatically improve, asmany as 20% may experience anxiety or depressive symptoms that requiretherapy, Wittgrove says.
"Acute symptoms of depression signal the need for psychiatricreferral," Sugerman says. "Those with pre-existing depressionshould also be carefully managed by a specialist." 
Bariatric Surgery at a Glance
BY BRUCE GOLDFARB
One recent report suggests that the number of bariatric surgeries in theU.S. increased from 13,365 in 1998 to 72,177 in 2002 and was projected toreach 102,784 in2003.1
According to the American Society of Bariatric Surgery (ASBS), the numberof bariatric surgical procedures for obesity reported by members increasednearly threefold, from 36,700 to 103,200, during 2000–2003.
Bariatric surgical procedures are classified as restrictive ormalabsorptive. Restrictive procedures reduce the size of the stomach to apouch about 1 oz in size that can stretch to 2 or 3 oz, limiting the amount offood a person can eat. Malabsorptive procedures alter the course of thedigestive tract to reduce the body's ability to absorb food. Some proceduresare a combination.
The most commonly performed procedures in the U.S.include:2
Vertical banded gastroplasty (VBG) The most commonly performedbariatric surgery procedure, VBG is a restrictive procedure using staples anda plastic band to create a small upper gastric pouch. It usually results inloss of 50–60% of excess body weight (EBW) and about 25–30% ofbody mass index (BMI), peaking at about 2 years. Operative mortality whenperformed by a skilled surgeon is about 0.1%, and operative morbidity is about5%.
Roux-en-Y gastric bypass Considered the "gold standard,"the Roux-en-Y is the most common bypass surgery performed in the U.S.,accounting for more than 70% of procedures. A malabsorptive/restrictiveprocedure, the Roux-en-Y involves the creation of a small gastric pouchcombined with a gastrointestinal bypass. Weight loss is typically 65–70%of EBW and BMI loss is about 35%, peaking at 1–2 years with somesubsequent weight regain. Operative mortality when performed by a skilledsurgeon is about 0.5%, and operative morbidity is about 5%.
Biliopancreatic diversion This malabsorptive/restrictive procedurecreates a 3.4- to 5-oz pouch by partial gastrectomy, resulting in aninhibition of fat absorption. The duodenal switch is a variation that sparesthe pyloric valve. Patients lose about 70% of EBW and 35% of BMI. Operativemortality when performed by a skilled surgeon is about 1%, and operativemorbidity is about 5%.
Gastric banding Gastric banding is a restrictive procedure thatemploys an adjustable band to create a gastric pouch about 1 oz in size.Patients lose about 50% of EBW and 25% of BMI after 2 years. Operativemortality when performed by a skilled surgeon is about 0.1%, and operativemorbidity is about 5%.
Postoperative Nutritional Support
BY BRUCE GOLDFARB
Patients who undergo bariatric surgery require careful monitoring andmanagement to help them get used to the workings of their new digestivesystem, particularly after bypass procedures that alter the absorption ofnutrients, say experts who discussed the subject at the 46th annual meeting ofthe American College of Nutrition last fall.
"We have to help patients realize that this is a lifelongdiet," says Ann Smith, RD, CDE, diabetes educator with the diabetesmanagement program at Clark Memorial Hospital in Jeffersonville, Ind.
Among the most frequently reported problems are bloating, nausea, andvomiting, which often result from consuming too much food or liquid. Patientsneed to learn how to pace their eating in order to get sufficient nutrientswith the least unpleasant effects, Smith says.
Maintaining adequate amounts of fluid is important, and Smith recommends48–64 oz of water per day. Patients should stop drinking about a halfhour before meals to minimize the risk of vomiting.
Patients must learn to eat smaller amounts of food throughout the day toaccommodate their smaller gastric pouch and earlier sensation of satiety. Evenso, maintaining a well-balanced diet can be difficult. Patients should consumea minimum of 60–80 g of protein per day, which many achieve with proteinpowders or bars.
"Because the postsurgical diet has so little fiber, constipation canbe a problem," Smith says.
Gastric bypass patients are prone to nutritional deficiencies, such asthose of vitamin D, iron, vitamin B12, and thiamine. "Patients can'tabsorb a lot of fat, so they can't absorb a lot of fat-soluble vitamins,particularly A, D, E, and K," says Charlotte Gollobin, MS, LN, adietitian and nutritionist in Rockville, Md.
Christopher Still, DO, medical director of the Center for Nutrition andWeight Management at the Geisinger Health Care System in Danville, Pa., saysonce the vitamins are in normal range, he usually checks levels at 6 monthsafter surgery and then yearly. He checks vitamin B12 levels more frequently ifthe patient is not getting a B12 injection every 3 months.
Some clinicians may be concerned with carotene. With regard to betacarotene, an antioxidant that also plays a role in vitamin A metabolism, Stillsays, "I do not currently follow carotene levels in our post-op surgicalpatients."
Experts recommend a daily multivitamin to ensure patients cover theirnutritional bases.
"A lot of bariatric surgeons are telling their patients to take achildren's chewable multivitamin, and that's just not enough," Gollobinsays.
Footnotes
The American Society for Bariatric Surgery maintains a searchabledatabase of qualified surgeons.
American Society for Bariatric Surgery 199 S.W. 75th St., Suite 201Gainesville, FL 32607 352-331-4900www.asbs.org
The American Obesity Association offers information on obesitysurgery on its Web site atwww.obesity.org/education/advisor.shtml.
Material for health professionals and patients developed by theWeight-control Information Network (WIN), a service of the National Instituteof Diabetes and Digestive and Kidney Diseases (NIDDK), is available online athttp://win.niddk.nih.gov/publications/gastric.htm.The material is not copyrighted, and users are encouraged to duplicate anddistribute as many copies as desired.
References
2. Moore KA, Ouyang DW, Whang EE: Maternal and fetal deaths aftergastric bypass surgery for morbid obesity. N Engl JMed 351:721–722, 2004.
3. Alvarez-Leite JI: Nutritional deficiencies secondary to bariatricsurgery. Curr Opin Clin Nutr Metab Care 7: 569–575, 2004.[Medline]
2. Buchwald H for the Consensus Conference Panel: Bariatric surgeryfor morbid obesity: Health implications for patients, health professionals,and third-party payers. J Am Coll Surg 200: 593–604, 2005.[Medline]
CiteULike 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||
|
||||||
|
| DOC News | Diabetes | Diabetes Care | Clinical Diabetes | Diabetes Spectrum |
